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Procedure

Owning committee name

Patient Care

(Temporarily managed by FHIR Core with review from Patient care)

Contributing or Reviewing Work Groups

None

FHIR Resource Development Project Insight ID

Pending

Scope of coverage

An action that is performed on a patient. This can be a physical 'thing' like an operation, or less invasive like counselling or hypnotherapy.

An Act whose immediate and primary outcome (post-condition) is the alteration of the physical or mental condition of the subject. Used to record the details of procedures performed on a patient. This includes surgical procedures, diagnostic procedures, endoscopic procedures, biopsies. It also includes group therapy, training, psycho-therapy, music therapy, etc. It does not include drug therapy, chemotherapy, radiation therapy, light therapy or other therapies where "dosage" is a primary aspect of the intervention.

Procedure specifically excludes activities whose primary activity is the introduction of medications or similar substances (Immunization, MedicationAdministration). The focus of the Procedure resource is the actual activities performed, as opposed to Observation and DiagnosticReport which may be used to capture information learned while performing a procedure. Activities whose sole purpose is to gain information without performing any significant disruption of the subject (e.g. MRI, colonoscopy, etc.) are not technically Procedures, though because of the scheduling, possibility of use of anesthetic, etc. many systems may choose to represent them as Procedures.

When capturing planned/intended procedures, CarePlan or Appointment should be used.

RIM scope

Procedure[classCode=PROC, moodCode=EVN]

Resource appropriateness

Procedures are a common activity within medical practice and recorded by most EMR systems.

Expected implementations

A part of CCDA so can be expected to be implemented by most systems that support this. There are many specialist systems (particularly for surgical procedures) that record details of procedures.

Content sources

CCDA, openEHR, Affiliate specifications, existing systems

Example Scenarios

  • Appendectomy
  • Biopsy
  • Counselling session

Resource Relationships

The procedure resource is linked to:

  • Patient resource as the subject
  • Practitioner resource as the author
  • DiagnosticReport for the report of the procedure
  • Procedure/MedicationPrescription as related resources

It is likely the Specimen will also be included once that resource is specified.

Timelines

Expected to be balloted DSTU in September 2013

gForge Users

david_hay

Issues

  • Revamped to clarify relationship to MedicationAdministration, Observation and DiagnosticReport. Also expanded examples for non-surgical procedures and gave guidance on observations typically treated as procedures.
  • Need to confirm that light therapy, radiation, etc. aren't covered here. Where should ultrasound therapy live?
  • Why/how would specimen relate to Procedure? As a product? Specimen now exists, so if it's in the 80%, add it.
  • Need better/tighter explanation of "related resources". Related how?